**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident had a right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 14 residents (Resident #4) reviewed for accommodation of needs. Resident #4's call light was not within her reach. This failure could place residents at risk of not having their needs met and a decline in their quality of care and life. Findings included: Record review of Resident #4's face sheet, dated 07/17/2024, revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included, but were not limited to, parkinsonism (slowed movements, tremors), urinary tract infection, dementia (memory loss), anxiety disorder, neuromuscular dysfunction of bladder (incomplete bladder emptying), and a history of falling. Record review of Resident #4's quarterly MDS, dated [DATE], revealed a BIMS score of 00 out of 15 which indicated Resident #4 had severe cognitive impairment. Resident #4 required extensive two-person staff assistance with toileting hygiene, upper and lower body dressing, and personal hygiene. Record review of Resident #4's care plan, dated 05/07/2024, revealed, in part, Resident #4 had urinary/bowel incontinence with interventions to keep call light in easy reach and remind resident to call for assistance when urgency to eliminate was noted. Resident #4 was at risk for injuries from falling related to physical mobility and generalized weakness with interventions to ensure call light was in reach and answered promptly. During an observation and interview on 07/17/2024 at 8:34 AM, Resident #4 was sitting in her recliner in the middle of her room, she had a blanket covering her body. Resident #4 stated she needed to go to the bathroom. Observation of Resident #4's private room revealed that her designated call light located closest to her bed was on the floor. A second call light for that room that would have been designated for a roommate was located on Resident #4's bed out of reach from Resident #4. When asked about how long she was in the recliner needing help, Resident #4 did not answer the question. In an interview and observation on 07/17/2024 at 8:43 AM, CNA B stated that Resident #4 could not transfer herself and that she and another aide transferred her into her recliner. CNA B walked into Resident #4's room and noticed the call light was not in residents reach. CNA B apologized to surveyor for the call light being on the bed and not near Resident #4. CNA B stated that a possible negative outcome for not having the call light in reach could be that a resident could fall and would not be able to call for help. In an interview on 07/17/2024 at 9:40 AM, LVN A stated that it was protocol for call lights to be in reach of residents and the negative outcome for a resident not having a call light in reach would be that a resident could try to get up on their own and could hurt themselves. In an interview on 07/17/2024 at 2:37 PM, the ADON stated that it was protocol when residents were transferred from their bed to a chair in their room that the call light was to be placed near the resident. The ADON stated that the possible negative outcome for a call light out of reach of a resident could be that they could fall and need help. In an interview on 07/17/2024 at 2:40 PM, the DON stated that staff had been inserviced on call light placement and that a possible negative outcome for a resident that was not able to reach their call light could be that the resident would need help and not be able to call for help. Record Review of the policy titled Call light-use of dated 12/2017 revealed the following in part: .It is the policy of this home to ensure residents have a call light win reach that they are physically able to access and that have been instructed on its use. .All nursing personnel must be aware of call lights at all times. .When providing care to residents, be sure to position the call light conveniently for the resident to use. Tell the resident where the call light is and show him/her how to use the call light. .Be sure call lights are placed near the resident, never on the floor or bedside stand.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail, assess the resident for risk of entrapment from bed rails prior to installation, and review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for1 of 14 (Resident #13) residents reviewed for bed rails. Resident #13 had (1) one-third bed rail, on the right side of her bed with no documentation of resident consent, or safety assessment prior to installation. This failure could place residents at risk of injury, hinder residents from getting out of bed, and/or cause a decline in resident's ability to engage in activities of daily living. Findings included: Record Review of Resident #13's Face Sheet dated July 16, 2024revealed that a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that include but not limited to weakness, cognitive communication deficit, unspecified dementia (memory loss) and major depressive order. Record Review of Resident #13's Quarterly MDS assessment dated [DATE] revealed Resident #13 had a BIMS score of 01 indicating that resident had severe cognitive impairment. The MDS revealed that Resident #13 required a 2 person assist with lying to sitting on side of bed, sitting to standing and chair to bed transfer. Record Review of Resident #13's Care plan dated 5/01/2024 revealed the following with no documentation relating to side/bed rail use. Focus: Dementia with cognitive impairment Interventions: Reorient resident as needed. Focus: Limited physical mobility Interventions: Provide supportive care, assistance with mobility as needed. Record Review of Resident #13's clinical record dated 10/09/2023 revealed physician's standing orders of side rails to be used when assessment revealed necessary. Record Review of Resident #13's clinical record under Assessments revealed no documentation of bed rail safety assessment for 1/3 size bed rails. Record Review of Resident #13's clinical record under Assessments revealed an assessment was completed on 10/09/2023 for 1/8 size bed rails. Record Review of Resident #13's clinical record for bed rail consents revealed no documentation of a signed bed rail consent for 1/3 size bed rails. Observation on 07/16/2024 at 10:42AM of Resident #13's bed revealed (1) 1/3 size bed rail on the right side of bed. Observation on 07/17/2024 at 8:30 AM of Resident #13's bed revealed bed rail was no longer on the bed. In an interview on 07/17/2024 at 9:40 AM, LVN A stated that assessment and consents were required for bed rail use. LVN A stated she did know that the bed rail had been taken off the bed but stated that maintenance was responsible for bed rails installation and removal. LVN A stated that a possible negative outcome for bedrails being used without assessments could be that it could cause entrapment, or a resident could try to crawl over the bed rail and get hurt. LVN A stated she did not know what size bed rails were on Resident #13's bed. In an interview/observation on 07/17/2024 at 2:00 PM, Resident #13 was sitting in her recliner. When asked about the bed rails being on her bed, Resident #13 waved her hands back and forth to the side saying, it doesn't matter. Resident #13 was bilingual and to ensure she understood surveyor, CNA C entered the room and relayed the question in Spanish concerning the bed rails. CNA C stated that that Resident #13 didn't care if bedrails were on or off the bed. In an interview on 07/17/2024 at 2:06 PM, the MS stated that he was directed by ADON to take bed rails off the bed on 07/16/2024. The MS stated that the bed rail on Resident #13's bed was 1/3 in size. In an interview on 07/17/2024 at 2:38 PM, the ADON stated she directed MS to take the bed rail off the bed because the family requested the removal. The ADON stated she did not know what size of bed rail was on Resident #13's bed. The ADON stated that a possible negative outcome for having bed rails on the bed was that a resident could be stuck in the bed. In an interview on 07/17/2024 at 2:40 PM, the DON stated that she did not know what size of the bed rails that were on the bed and stated that a possible negative outcome for unneeded bed rails on the bed would be that the resident wouldn't be able to get out of bed. Record Review of facility policy title Bed Rails dated November 8, 2016, revealed the following: Assessment-Prior to use of a bed rail the resident will be assessed to ensure the proper rail is utilized for the resident's need. The facility will re-evaluate the use of the rail on a periodic basis. Based on the resident assessment, the interdisciplinary team will make the determination for the plan of care as it relates to bed rail. Consent-The resident or resident representative will provide consent for the use of rails prior to installation.

Based on observation, interview, and record review; the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 of 2 medication carts (Hall 200) and 1 of 1 medication room reviewed for drug labeling and storage and expired drugs. 4.5 pills were loose in the bottom of medication cart drawers of Hall 200 Medication cart. Medication room revealed a medication for Resident #36 that expired in June of 2023. These failures could result in residents not receiving an accurate dose of medication as well as not being maintained at their best therapeutic level. Findings included: Observation and interview on 07/16/2024 at 10:26 AM of medication room revealed a medication for Resident #36 that had an expiration date of 06/2023. LVN D stated that the medication was discontinued and was not sure why the medication was still in the medication room. LVN D was unable to give a negative outcome for having expired medication in the medication room. Observation on 07/16/2024 at 10:46 AM revealed 4.5 pills were found loose on the bottom of the medication cart drawers for medication cart for 200 Hall. MA was not able to identify any of the medications. Interview on 07/16/2024 at 10:54 AM, MA stated that the negative outcome for having lose medication could result in the resident not receiving their medications. Interview on 07/17/2024 at 11:11 AM with DON, requested policy for medication storage. DON was asked what a negative outcome would be for having loose medications in the medication cart. DON stated, missed dose. No further information was provided by DON. Record review of facility provided policy, titled Storage of Medications, revised April 2007, revealed the following: 1. Drugs and biological shall be stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. . 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Record review of facility provided policy, titled Labeling of Medication Containers, revised April 2007, revealed the following: Policy Statement All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations. Record review of facility provided policy, titled Drug Destruction Policy, revised May 9, 2010, revealed the following: It is the policy of this facility to destroy dangerous and controlled medications according to the State of Texas law. .3. Nursing staff will submit to Director of Nursing any medication and any applicable log that has expired, been discontinued by physician or that had been prescribed to a resident who no longer resides at the facility.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure freezer items were properly stored, labeled, and dated. 2. The facility failed to ensure pantry foods were properly stored, labeled, and dated. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings included: In an observation of the walk-in pantry on 07/16/2024 at 8:50 AM the following was observed: 1. (4) graham cracker pie crusts in a package, not sealed and open to air with no date or label. 2. (1) open gallon of Big Chief Imitation Vanilla Flavor expiration date April 16, 2024, with no open date. In an observation of the freezer on 07/16/2024 at 8:55 AM the following was observed: 1. (1) box of hamburger patties with approximately 20 patties in the box, open to air with no open date. A small amount of freezer burn on the top patties was observed. In an interview on 07/18/2024 at 9:15 AM, the DC stated all employees were responsible for disposing of expired foods or foods that were not any good. The DC stated that the negative outcome for not throwing away expired items would be that residents could get sick. The DC stated that all employees were also responsible for labeling and sealing any items in the dry food area, refrigerator, and freezer area. In an interview on 07/18/2024 at 9:20 AM, the DS stated that she and her employees were responsible for ensuring foods were labeled and sealed. The DS stated that all employees were responsible for disposing of expired items. The DS said that a possible negative outcome for expired or open foods would be that a resident could get sick or contact pathogens and that not sealing or labeling foods properly could cause freezer burn on the foods. In an interview/observation on 07/18/2024 at 9:30 AM, the DS removed the open pie crusts from the shelf in the Dry Pantry and told Surveyor that she did not know when the item was opened as it was not labeled. Record review of facility provided policy (no date) titled Labeling and Dating Food stated in part: When the food item is removed from the original box, each item must be dated, or container must be dated. Once you open a food item, you must date it the day it was opened. Record review of facility provided policy (not date) titled Dry Storage and Supplies stated in part: Open packages of food are stored in closed containers with tight covers and dated as to when opened. Record review of facility provided policy (not date) Food Safety stated in part: Food is to be tightly wrapped or sealed and covered. Opened food shall be labeled, dated and stored properly. Do not keep potentially hazardous food past the labeled expiration date.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 (LVN D, LVN E, CNA G, and CNA H) of 4 staff members and 2 of 2 residents (Resident #2 and Resident #45) in that: LVN E did not don PPE gown before administering ordered medications via Peg-tube to Resident #2 LVN E did not don PPE gown before administrating Foley Catheter Care, Incontinent Care, and Wound Care-Stage 3 pressure ulcer to coccyx on Resident #45 CNA G did not don PPE gown before assisting LVN E with Foley Catheter Care, Incontinent Care and Wound Care Stage 3 pressure ulcer to coccyx on Resident #45 CNA H did not don PPE gown before, assisting LVN E with Foley Catheter Care, Incontinent Care, and Wound Care-Stage 3 pressure ulcer to coccyx on Resident #45 LVN D did not don PPE gown before administering liquid feeding via Peg-tube to Resident #2 These deficient practices have the potential to affect all residents in the facility by exposing them to care that could lead to the spread of viral infections, secondary infections, communicable diseases. Findings include: Observation on 7/17/24 at 8:50AM revealed LVN E did not don PPE gown for the administration of ordered medications for Resident #2's PEG-tube. PPE gown was not present inside room or in hallway outside the door of Resident #2's room. Record review of Resident #2's admission Record states Resident #2 is a 48 y/o female admitted to facility on 7/1/2007. Medical diagnoses include a diagnosis of Cerebral Palsy. Care Plan dated 7/9/24 states Resident requires total assist with ADL needs, is incontinent of bowel and bladder, must maintain nutritional status via tube feeding related to inability to swallow, and receives all medications, feedings, and fluids via peg tube. Observation on 7/17/24 at 9:33AM revealed that LVN E, CNA G, and CNA H did not don PPE gowns during Foley catheter care, Incontinent bowel care followed by Wound care for Stage 3 pressure ulcer to coccyx for Resident #45. No gowns were used in any of the procedures performed. No gowns were in Resident #45's room or in the hallway outside Resident #45's door. Record review of Resident #45 admission Record states Resident #45 is a 61 y/o male initially admitted to facility on 2/8/24. Medical diagnoses include Pressure Ulcer of Sacral Region Stage 3 and Obstructive and Reflux Uropathy. Care Plan dated 5/28/24 states; Resident is incontinent of bladder and requires an indwelling Foley catheter, Sacral pressure ulcer stage 3, needs staff assistance for ADLs, and 2 staff members to transfer. Observation on 7/17/24 at 11:45AM revealed LVN D did not don PPE gown, before administration of ordered feeding for Resident #2 via her Peg-tube. PPE gown was not present inside room or in hallway outside her room. Interview on 7/17/24 at 11:55AM LVN D stated she had not been told to wear a gown as part of PPE when using Peg-tube for feeding residents. She did not know what Enhanced Barrier Protection (EBP) meant. She stated a negative outcome of not donning a PPE gown during care is that germs can spread. Interview on 7/17/24 at 1:01PM CNA G stated she had never been told to wear a gown when changing or assisting with any resident care. She did not know what Enhanced Barrier Precautions (EBP) were. She stated a negative outcome of not donning a PPE gown could be Spread of Infection. Interview on 7/17/24 at 1:08PM CNA H stated she had heard talk about wearing a gown, she could not remember who had told her. She stated a negative outcome of not donning a PPE gown ring resident care could be, Infection to the resident. Interview on 7/17/24 at 1:28PM Charge Nurse LVN A stated she had never heard of Enhanced Barrier Precautions (EBP). She did not remember an in-service on EBP being done. She stated a negative outcome of not donning a PPE gown during resident care could be, Possibility of getting bacteria on clothes and transferring. Interview on 7/17/24 at 1:33PM DON stated she was not aware of EBP policy. She was not aware of any in-service or training for staff. When asked what a possible negative outcome could be for not donning a PPE gown during resident care she first stated, I don't know. Administrator was in room and stated to her, Organisms if there are any, and she repeated to Surveyor, Organisms if there are any. Interview on 7/17/24 at 1:38PM with Administrator. He stated he was aware of EBP policy. He stated there had been an in-service on it and he would find it. He stated he had gotten a resignation from facilities former DON who had been at facility for 14 years, on March 31, 2024. The current DON started in April of 2024. Current DON may not have known about EBP policy he stated. When asked what a possible negative outcome could be for not donning a PPE gown during resident care he stated, Possibility of transfer of organisms. Interview with LVN E attempted. Tried to contact by phone on 7/17/24 at1:45PM, 1:46PM and 7/18/24 at 9:49AM. Left Voicemails requesting call back. Unable to contact LVN E and she was not working at facility after 12:00PM on 716/24. Did not work through 7/18/24. Record review of facility provided policies, procedures, CMS, and CDC updates received, and in-service: Inservice Titled 'Infection Control, [NAME] & Doffing, Enhanced Barrier Precaution-catheter/wound/peg-tube,' which included: Record review of facility provided Inservice document titled CMS OSO-24-08-NH Dated March 20,2024 effective April 1, 2024, revealed the following: .Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO's) that employs targeted gown and glove use during high contact resident care activities.' .Examples of chronic wounds include, but not limited to pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. .Indwelling medical device examples include central lines, urinary catheters, feeding tubes .EBP is employed when performing the following: Providing hygiene, Changing briefs or assisting with toileting, Device care or use .urinary catheter, feeding tube, wound care any skin opening requiring a dressing. Record Review of Facility provided Inservice document titled; 'CDC Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDRO's)' updated July 12, 2022, under Key Points revealed: 2. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. 4. Effective implementation of EBP requires staff training on proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at point of care. Record review of Facility provided Policy Titled: 'Enteral and Parenteral Feeding' dated 12/02/2017 under Procedure revealed: 12. Standard precautions, clean techniques, applicable nursing policies, and manufacturer's recommendations are followed by nursing personnel when dealing with nutrition support residents. DON and/or designee are responsible for training and monitoring of nursing personnel on Nutritional Support procedures, documentation, and orders. Record review of Facility provided Policy Titled: 'Administering Medications' dated December 2012 under Policy and implementation revealed: 22. Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic techniques, gloves, isolation precautions, etc.) for the administration of medications as applicable. Record review of Facility Policy Titled: 'Perineal Care Male' dated December 8, 2009, under Gather Supplies revealed: Gather needed supplies: i. Washcloths or Pre-moistened cleaning wipes ii. Towels iii. Soap or no-rinse perineal cleanser iv. Clean wash basin(s) or comfortably warm water v. Clean, disposable examination gloves vi. Overbed table vii. Disposable plastic bags for trash and linen viii. Incontinence pad(s) or brief ix. Additional supplies as needed if heavy soiling is present, i.e., toilet paper. Record review of Facility provided Policy Titled: 'Catheter Care dated February 13, 2007, under Procedure revealed: 1. Gather Supplies: a. Gloves b. Pre-moistened no-rinse disposable wash cloths c. Or wash cloths and basin (if using soap and water) Record review of Facility provided Policy Titled: 'Infection Control Plan': Overview dated 2018 under Facility Assessment revealed: At least annually and on an as needed basis the facility will conduct a facility wide assessment to determine the resources needed to maintain and efficient and up to date infection control program. The facility assessment can assist in determining the types of residents being cared for, what is needed to care for those residents, and what education facility staff need.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 14 residents (Resident #1) reviewed for immunization records. The facility failed to ensure records regarding patient care, including bed rails, was accurate and complete. This deficient practice placed residents at risk for inaccurate records to ensure continuity of and appropriate care. Findings included: Record review of Resident #1's face sheet dated on 6/8/23 revealed a [AGE] year-old woman who was admitted into the facility on 3/26/23. Diagnoses included encephalopathy (disease that affects the brain causing altered mental status), hyperlipidemia (elevated lipids), unspecified psychosis, disorientation, cardiac arrhythmia, hypo-osmolality and hyponatremia (low plasma). Record review of Resident #1's MDS assessment dated [DATE] indicated a brief interview for mental status of 05 indicating severe cognitive impact. Record review of Resident #1's bed rail assessment dated [DATE] showed not completed by the admitting nurse. Record review of Resident #1's bed rail consent dated 3/6/23 showed not completed by the admitting nurse and signed by the resident representative. Record review of Resident #1's Influenza Informed Consent (no date) showed not completed but signed by the resident representative. Record review of Resident #1's Pneumococcal Informed Consent dated 3/6/23 showed not completed but signed by the admitting nurse and resident representative. Interview with the DON on 06/09/23 at 10:52 AM revealed that the charge nurse did bed rail assessments when a resident was admitted . The DON stated what information was on the Bed Rail assessment. DON indicated the size of rail, if there was one, and what side. The DON revealed LVN C was a charge nurse. DON looked at the form, confirmed it was LVN C's signature and it was not completed correctly. The DON stated a negative outcome could be with an uncompleted assessment, she could have a rail and not need one. Interview with LVN C on 06/09/23 at 11:04 AM revealed needing a bed rail assessment is the reason for needing it and the patient's ok if they want to use them or not. The reasons why it would help them LVN C identified the resident or resident representative could sign the consent. LVN C stated a negative outcome could be entrapment if they are caught in the bed rail. If something was to happen to them. LVN C confirmed that LVN C's signature was on Resident #1's Bed Rail Assessment form dated 3/6/23. Interview and record review with the DON on 6/9/23 at 11:08 AM revealed the charge nurse completed bed rail assessments upon admission. The DON stated the type of rail that had been determined and the resident signature or the person giving consent was needed. The DON revealed that a negative outcome for an incomplete form if signed by both nurse and Representative/Resident meant it was completed without something being fully assessed. The DON confirmed the consent for Resident #1's bed rails was not completed and confirmed the signature on the form was LVN C's. Interview and record review with LVN C on 6/9/23 at 2:25 PM revealed Resident #1's influenza and pneumococcal consents were not completed. LVN C revealed obtaining the signatures before completing the forms. LVN C confirmed completed admission paperwork for Resident #1. LVN C stated LVN C called the clinic but it was close to end of shift. Told them (employees) if they call this is what we are looking for. I told them I just needed a record for chart. I know I messed up. It's my fault. LVN C confirmed did not get a yes or no on the Influenza Consent and that the Pneumococcal Consent was not filled out correctly with her signature at the bottom. LVN C identified a negative outcome of being unable to tell if resident has had the vaccine or needs the vaccine since forms were not completed. Record review of policy titled Documentation dated 2003 with a revision on 2/13/2007 indicates that documentation is the recording of all information in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. Record review of policy titled Documentation dated 2003 with a revision on 2/13/2007 Under heading Goal-Line (1) states the facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. Record review of policy titled Documentation dated 2003 with a revision on 2/13/2007 under heading Procedure Line (3) Place all required and appropriately signed forms in the clinical record. Items such as copies of .consent for treatment, consents for specific procedures . will be placed behind labeled dividers inside the clinical record. Line (6) document completed assessments in a timely manner and per policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to keep resident rooms free from accident hazards for 3 of 3 residents (Residents #13, #19, #20) who were observed. The facility failed to follow smoking policy by Resident #13, Resident #19 and Resident #20 having smoking materials of lighters and cigarettes in rooms. This failure could place residents at risk of accident hazards. Findings included: Resident #13 Record review of Resident #13's face sheet dated 6/8/23 revealed a [AGE] year-old male admitted into the facility on 5/29/2018. Resident #13's diagnoses included: aphasia (communication deficiencies), muscle wasting and atrophy, cognitive communication deficit, mood disorder, chronic embolism and thrombosis (deep veins in the lower extremities), vascular dementia, nicotine dependence, and major depressive disorder. Record review of Resident #13's MDS assessment dated [DATE] revealed a BIMS score of 02 and required extensive assistance or two-person assist in all areas of daily living except locomotion on and off unit with limited assistance. Record review of Resident #13's care plan dated 5/23/23 revealed a focused goal for smoking and was at risk for injury with additional information that resident can smoke independently. Record review of Resident #13's smoking assessment dated [DATE] revealed that all resident's smoking materials will be kept at the nurses' station. Observation on 6/8/23 at 11:19 AM revealed two lighters, one pink and one yellow, sitting on Resident #13's rolling bed side table. Interview with Resident #13 on 6/8/23 at 11:19 AM revealed that Resident #19's cigarettes were kept in the med cart but can keep lighters. Resident #13 indicated that they are allowed to smoke independently. Resident #19 Record review of Resident #19's face sheet dated 6/8/2023 revealed resident was a [AGE] year-old female whose diagnoses included: malignant neoplasm of vertebral column (cancer of the spine), complications after genitourinary (reproductive) surgery, muscle wasting and atrophy (shrinkage), cognitive communication deficit, hyperglycemia (high blood sugar), lack of coordination, abnormalities of gait and mobility, ataxia (loss of coordination), anxiety disorder, gastro-esophageal reflux disorder, quadriplegia, major depressive disorder, c4 level cervical spinal cord, malignant neoplasm of brain (cancer). Record review of MDS assessment for Resident #19 dated 03/31/23 indicated a BIMS of 14. Record review of Resident #19's smoking assessment dated [DATE] revealed that all resident's smoking materials will be kept at the nurses' station. On 6/8/23, observation and at 7:49 AM revealed Resident #19 sitting in her wheelchair in her room. Resident #19 stated lighter was in room and a red lighter was observed to be on Resident #19's bed. In an interview on 6/8/23 at 7:49 AM with Resident #19, resident stated the lighter was in her room even though Resident #19 knew it was not supposed to be there. Resident #19 indicated that they were at the nurse's station. Resident #19 stated that assistance was needed to go smoke as Resident #19 was not able to transport independently outside. Record review of Resident #19's chart shows smoking assessment where Resident #19 is unable to smoke independently and uses assistive devices. Resident #20 Record review of Resident #20's face sheet dated 6/8/23 revealed a [AGE] year-old woman admitted into the facility on 8/26/2019. Resident #20 had diagnoses: morbid obesity, generalized anxiety disorder, heart failure, hypercholesterolemia (high cholesterol), schizoaffective disorder; depressive type, Type 2 Diabetes, nicotine dependence, and schizophrenia. Record review of Resident #20's care plan dated 5/16/23 revealed a focused goal of smoking without assistance. Record review of Resident #20's MDS assessment dated [DATE] revealed that resident had a BIMS score of 11 indicating cognitively intact. Resident #20 needed minimal/supervising assistance with areas of daily living. Record review of Resident #20's smoking assessment dated [DATE] revealed that resident smoking materials will be kept at nurses' station. Interview and observation with Resident #20 on 6/8/23 at 7:36 AM revealed that Resident #20 was allowed to smoke alone. Resident #20 showed smoking materials ofa blue lighter in left hand. Resident #20 also advised that cigarettes were kept at the medication cart. Observation on 6/8/23 at 11:35 AM showed two packages of Montego Gold 100's-one opened and one unopened. Observation on 6/8/23 at 11:48 AM, LVN E opened the medication cart to reveal one pack of Montego Blue 100's in the left drawer behind liquid items. Interview with LVN B at 11:32 AM revealed that there was one smoker on four hall at that time. LVN B stated Resident #20's smoking materials were kept in the facility at the medication cart. LVN B showed the surveyor where Resident #20's cigarettes were in the medication cart which was the top right corner. LVN B indicated that there were only two smokers in the building. LVN B stated that a negative outcome would be Fire hazard. LVN B indicated that Resident #19 had a lighter and cigarettes in room. LVN B stated, I know they are not supposed to. LVN B revealed that the Smoking policy stated they were not supposed to have anything in their rooms, and they were either kept in the medication cart or the medication room because they are locked. Interview with CNA F on 6/8/23 at 11:45 AM revealed one resident that smokes in five hall. Inquired which resident and identified Resident #13. CNA F stated that cigarettes were in the medication cart. CAN F stated Resident #13 keeps lighter and a negative outcome of the resident keeping the lighter would be a fire hazard. CNA F also stated that resident was allowed to have a lighter when resident was of sound mind. CNA F stated smoking policy revealed they were to be supervised while outside. Interview with LVN E on 6/8/23 at 11:48 AM revealed LVN E was not aware of Resident #13's lighter location and that resident has never had a lighter on him. LVN E stated a fire hazard as a possible negative outcome. LVN E indicated that lighters were not allowed in rooms. LVN E stated the smoking policy revealed, not without going back and looking at it. Interview on 6/8/23 at 1:49 PM with LVN B revealed new cigarettes in the med cart labeled Marlboro Red 100's with Resident #19's name in black marker in top right-hand corner. LVN B advised that cigarettes were brought back to the medication cart LVN B advised that CNA went into resident's room and returned them to the medication cart. Interview on 6/8/23 at 1:54 PM with DON. The DON advised there were no in-services on the smoking policy and training is completed upon initial hire date. DON advised the smoking policy is the residents are not allowed to go out without a staff member. DON indicated that smoking materials are kept in the medication cart. DON indicated that a negative outcome of residents keeping smoking materials in their room was would be confiscated; I don't know what you're asking. The DON responded with I don't know what you are asking, a lot of things can happen. Interview with the DON on 6/8/23 at 2:06 PM revealed that smoking assessments were completed upon admission and quarterly. Advised that RNs completed them upon admission and the ADON completed them quarterly. Interview with the ADON on 6/8/23 at 2:08 PM revealed that in-service for smoking was done upon hire. ADON advised that smoking policy stated smoking materials are in the medication carts separated from other items. The ADON also stated that there were three smokers in the building and a negative outcome of smoking materials being in resident's rooms would be a fire. Interview and record review with the DON, ADM, and ADON on 6/9/23 at 8:55 AM revealed that three policies were provided for smoking. One policy labeled Smoking Policy Resident/Family Copy (no date) identified residents were allowed to keep smoking paraphernalia in their room when supervised. DON indicated supervised meant they don't go by themselves, so they are supervised. The ADM indicated it meant that they know they have their smoking materials on them. The ADON walked into the room at 8:58 AM and indicated that the smoking assessment asked if they can be unsupervised, and verbiage is found on smoking assessment. ADM stated about smoking materials in resident's room, the care plan says that. ADON confirmed with head shake up and down. Interview with the ADM on 6/9/23 at 9:01 AM and inquired about record of policy in admission packet, policy provided to family, and facility policy with conflicting wording. Inquired which policy to go by since two were the same and Smoking Policy Resident/Family Copy (no date) stated smoking paraphernalia can be kept in room when supervised. The ADM stated, we will get that changed. Record review of policy named Items Not Allowed in Resident Room (no date), under Safety Hazards, last statement indicated Smoking or smoking materials-not allowed. Record review of policy named It is the policy of [the facility] to abide by the rules and regulations set forth by the Texas department of Aging and Disabilities, (no date), line 13 stated- Smoking tobacco, matches, lighters or other smoking paraphernalia are not permitted to be kept or stored in a resident's room or in their possession. Record review of Smoking Policy Resident/Family Copy (no date) revealed the following: Line 1, line (a) Smoking tobacco, matches, lighters or other smoking paraphernalia are not permitted to be kept or stored in a resident's room or in their possession with supervision.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored food was properly stored per food label. 2. The facility failed to practice proper hand sanitation while preparing food. Findings Included: Observation of shelved foods on 6/7/2023 at 10:00am revealed the following: 1. Plastic bottle labeled tartar sauce no expiration date noted ??? sitting on shelf with spice containers with a label on back indicated refrigerate after opening. Observation on 6/7/23 During an observation on 6/7/23 at 10:30 AM, observed [NAME] A preparing puree food. [NAME] A stopped prepping puree food, walked to trash can to discard a can, and returned to preparing puree food. Gloves were not worn, and no hand hygiene was practiced between these actions. During an interview on 6/8/2023 at 2:30pm with [NAME] A, DM, translated due to language barrier, stated that all kitchen staff are responsible for safe food preparation per their policy. [NAME] A stated that she would go to the Facility policy to see what the policy stated. [NAME] A stated that the negative outcome for not practicing hand hygiene would be cross contamination. Record review of in-service dated 1/9/23 at 1:30 PM, training contained hand washing and sanitation. Record review of policy titled Hand Washing, dated 2012, it stated that employees are too frequently perform hand washing. Record review of policy titled Handwashing: A Healthy Habit in the Kitchen, dated September 1, 2021, the policy stated : Clean: Wash Hands, Utensils, and Surfaces Often-Wash your hands often, especially during these key times when germs can spread: After touching garbage Record review of recommendations of the Food and Drug Administration (FDA), dated 1997, it states that the FDA has evaluated the labeling on foods that must be refrigerated to prevent outgrowth of pathogens- February 1997. Record review of FDA recommendations on Are You Storing Food Safely, dated 1/18/23, it stated Check storage directions on labels. Many items other than meats, vegetables, and dairy products need to be kept cold. If you've neglected to properly refrigerate something, it's usually best to throw it out.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible, in that: 1. The facility failed to ensure Oxygen was secured and transported in a safe manner in the resident transport van #1. This was in the presence of Resident #15 who required dialysis treatment transportation, and 2. The facility failed to ensure the resident transport van #1 was operated and maintained in a safe manner (unattended, unoccupied and engine running). These failures could place residents at risk for injuries related to compressed gas explosions or vehicle failure. The findings include: Record review of the physician Order Summary, dated 4/27/22, for Resident #15 revealed the resident was admitted on [DATE] and was a [AGE] years old female. The resident had diagnoses which included anemia and other chronic diseases classified elsewhere, hypertensive chronic kidney disease with stage five chronic kidney disease and end stage renal disease, dementia and other diseases classified elsewhere without behavioral disturbance, Alzheimer's disease, age related osteoporosis without current pathological fracture, cognitive communication deficit, other symptoms and signs involving cognitive functions and awareness and end stage renal disease. Resident #15 had an order for oxygen at 2-4 L/MIN via nasal cannula to keep O2 sats greater than 90% every shift or shortness of breath/PRN. The order date was 2/21/22. The resident also had an order stating, Resident to attend dialysis three times a week and PRN as dictated by nephrologist, order status active, order date 4/27/22. Record review of the annual MDS for the Resident #15, dated 11/18/21, revealed the resident was readmitted to the facility on [DATE] and initially admitted [DATE]. The MDS documented Special Treatments and Programs that included oxygen therapy and dialysis while a resident. An observation and interview on 4/25/22 at 12:26 PM of resident transportation van #1, which was parked outside of hall 400 where residents and staff smoked, revealed CNA A removed Resident #15 from the van in her wheelchair. He took the resident from the van, lowered her on the lift in her wheelchair, and took her into the facility through hall 400 exit, which passed through the resident smoking area. At that time, he left the van running unattended and unoccupied. He returned to the van at 12:27 PM and turned off the engine. An observation was made of Van #1's interior at this time and there was a small unsecured oxygen tank lying on its side in between the passenger and driver seat on the floor. The oxygen tank was filled and in the green dial zone at 1800 PSI. The label on the oxygen tank documented, DeVilble S S I Fill Personal Oxygen Station . Secure cylinder during storage and use . Do not drop . There was also a secured fire extinguisher, in the green dial zone (charged), that was next to the passenger side seat and unsecured oxygen tank on the floor. The extinguisher had no inspection tag. At that time CNA A stated, Resident #15 went to dialysis on Monday, Wednesday and Friday and identified her as the resident he had taken off the van and into the facility. During an interview and observation on 4/25/22 at 12:32 PM, CNA A stated, the oxygen tank needed to be secured and he would get it secured. He said there was no place to secure the oxygen in the van. Further observation of the interior of the van, at this time, revealed there were no devices available to secure the oxygen tank properly. CNA A stated he placed the tank in there van last week. He stated, he had been the van driver six months to a year. He added that he, the nurses and a few of the aides transport drive the van. He added, he took Resident #15 inside so she would not be cold. He added he tried to get them (residents) inside, then come back and turn the van off. He stated the van must be on for the lift to work. He stated, The Administrator and Maintenance conducted his training to be a transport aide. He stated he had not received any safety related training regarding not leaving the van running while unoccupied and unattended. He added, residents were not to be left in the van. During an interview on 4/25/22 at 1:06 PM with the Maintenance Supervisor revealed Regarding transportation aid training, he stated, he showed staff how the lift works, where the gas tank was and how to strap down the residents. He further added, the only time it's (van) left running is if the weather is hot or cold. He said the van is left running with no one in it (normally). During an interview on 4/25/22 at 6:11 PM with the Administrator regarding van transportation aide training documentation. He presented the Transportation Aide Job Description forms and stated this was the information was used to train transportation staff. In an interview on 4/27/22 at 10:00 AM with the Maintenance Supervisor revealed the van key was only a remote for locking the doors not for starting the engine. He stated, I have no idea why the oxygen was not secured. It (van) should have a (storage) bag on the side of it. He was also asked what the result could be if the oxygen was not secured. He stated, It could hit (something) and blow out. It could go (roll) under the brake pedal. He was also asked what the result could be if the van was left running unattended. He stated he was unaware of safety issues related to leaving the vehicle running, unoccupied and unattended. The surveyor then mentioned the possibility of theft and vehicle malfunction. He then added, It (van) could be stolen. On 4/27/22 at 1:40 PM an interview was conducted with CNA A regarding his use of the van #1 for transport. He stated, I used it for transport last week taking them to dialysis, Monday, Wednesday and Friday. Record review of the Human Resources Manual 2003, Revised: June 16, 2005, JD03 - 3/2.0, Job Description revealed the following documentation, Title: Transportation Aide . Essential duties: 1. Transport residents to/from medical facilities and/or other activities as needed in a safe manner . 3. Identify and report any condition requiring management or clinical attention during the transport . Record review of the attached facility document titled Van Driver Training revealed there was no mention of transportation of oxygen safety. There was no mention of vehicle safety related to leaving the vehicle unoccupied, running and unattended. Record review of the World Health Organization document, dated 1/05/21 titled, Oxygen Cylinder Safety, Intended for Health Workers and All Personnel Managing Medical Oxygen, revealed the following documentation, .Do Transport Cylinders Correctly . Ensure cylinder (regardless of size) is firmly secured by a strong chain or strap, capable of preventing the cylinder from falling or being knocked over . Do Store Cylinders Correctly . Store all oxygen cylinders in upright position and nesting, with three points of contact . Keep oxygen sources several meters from ignition sources (for example, acetylene used in maintenance). Ensure appropriate fire extinguishers are kept nearby and are regularly inspected . Record review of the website Automotive Fleet (https://www.automotive-fleet.com/323835/dangers-of-leaving-a-warming-up-vehicle#:~:text=Idling%20can%20strip%20away%20some,area%20where%20it%20is%20parked.) revealed the following documentation, Dangers of Leaving a Warming Up Vehicle, January 25, 2019, . First, leaving an unoccupied vehicle running invites theft . Thirdly, leaving an unoccupied vehicle running - even when it is in park - is never entirely safe. It causes excessive fumes in the area where it is parked. Moreover, motor vehicle systems do fail from time to time, and if the car should unexpectedly move or roll with no driver at the wheel, it could lead to a collision with another vehicle or a pedestrian . Record review of the facility policy titled Environment of Care Policy and Procedure Manual 2003, ME03 - 5.0, revealed the following documentation, Compressed Gases, Safe Handling of . 9. Never drop cylinders or permit them to strike against each other or against other surfaces violently. 10. When cylinders are moved, they should be securely chained to an appropriate transport vehicle. 11. When tanks are stored, all tanks and cylinders should be stored in a cylinder cart or securely chained in a secure storage area. Never leave cylinders freestanding. All cylinders must be individually secured by separate chains . Record review of the facility policy labeled Environment of Care Policy and Procedure Manual 2003, AD 03 - 5.0, revealed the following documentation, Environmental checklist. 1. An environmental checklist will be completed by the facility at least monthly. The environmental checklist is a self-audit that will bring to light unsafe conditions and unsafe practices within the facility and prevent accidents before they occur. Successful safety audit will assist the safety officer and the safety committee in understanding what improvements need to be made, and will provide a blueprint for the auditing team to follow in order to make changes to improve the safety of the environment within the facility . 3. Departmental supervisors may assist in their areas in completing the environmental checklist. Since the supervisors have direct contact with workers and are familiar with the practices of the department, they will play an integral part in safety audits. 4. Environmental audits will include the following areas . Building grounds and conditions .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F761 [NAME] Nursing and Rehabilitation Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable in two out of four medication carts, in that: The facility failed to ensure medications were properly labeled. The facility failed to ensure expired medications were not stored in the medication cart. These failures could place residents at risk of receiving other resident's medications. The findings include: Observation on 04/27/22 at 10:36 AM of medication cart A revealed one tube of Hydrocortisone 1% cream for Resident #17 that had no name or date on the tube, only on the box; one tube of Anti-itch cream for Resident #3 that had no name or date on the tube, only the box; one tube of Benzoyl Peroxide for Resident #47 that had no name or date on the tube, only the box; one tube of Nystatin Cream for Resident #25 that had no name or date on the tube, only the box; one tube of Triamcinolone Acetonide Cream 0.5% that had no name or date on the tube, only the box; one bottle of Artificial Tears for Resident #32 that had no name or date on the bottle, only the box; and one bottle of Artificial Tears for Resident #100 that had no name or date on the bottle, only the box. Observation on 04/27/22 at 10:55 AM of medication cart B revealed one tube of Diclofenac Sodium 1% gel and one bottle of Nitroglycerin 0.4mg/tablet for Resident #11 with no name or date on the tube or bottle, only the box; one tube of clotrimazole-betamethasone cream for Resident #8 with no name or date on the tube, only the box; two bottles of Alaway 0.025% solution eye drops for Resident #37 with no name or date on the bottles, only the box; and eight Chlorhexidine Gluconate 3.15% that expired on 01/22. In an interview on 04/27/22 at 10:45 AM, LVN C stated she did not know both the bottle and the box had to have the name and date on it. LVN C stated the medication carts were last checked by the pharmacy consultant last week. LVN C stated she did not know how these items were missed. LVN C stated all the nurses were responsible for checking the medication cart for properly labeled items. LVN C stated the residents were at risk for a possible drug reaction if they were given another residents medication. In an interview on 04/27/22 at 11:04 AM, LVN A stated she was not aware these needed to both be labeled. LVN A stated the medication cart was checked last week by the pharmacy consultant and she didn't know how the items were missed. LVN A stated all the nurses were responsible for checking the medication cart. LVN A stated the residents have a risk of allergic reaction if they were given another residents medications. In an interview on 04/27/22 at 11:15 AM, DON stated the medication carts were last checked last week by the pharmacy consultant. The DON stated she didn't know how these items were missed. The DON stated all the nurses are responsible for checking the medication cart for expired items and properly labeled medications every time they use the medication cart. DON stated the residents could have a reaction to a medication if it belonged to another resident. DON stated the medication may not work as well if were expired. Record review of the facility policy dated 2003 and titled, Medication labeling, reflected the following: Medications are labeled in accordance with facility requirements and state and federal laws Record review of the facility policy dated 2003 and titled, Storage of Medications, reflected the following: Medications and biologicals are stored safely, securely, and properly following manufacturers recommendations or those of the supplier

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 3 of 6 residents (Residents #4, #31 and #100) reviewed, in that: The facility failed to ensure Residents #4, #31 and #100 received pureed foods according to physician orders. This failure could place residents at risk of choking or aspiration incidents. The findings include: Record review of the facility's Order Listing Report Dated: 04/25/2022 revealed 5 residents were ordered puree consistency diets; Residents #4, #8, #21, #31, #47. Record review of the facility's Order Listing Report Dated: 04/25/2022 revealed the following residents also had orders for pureed diets: [Resident #21], regular diet. Puree texture, regular consistency, for difficulty swallowing, order status Active, revision date 10/20/2021 .[Resident #8], regular diet. Puree texture, regular consistency, for difficulty swallowing, order status active, revision date 3/19/2021 .[Resident #47], regular diet. Pureed texture, regular consistency, for double portions with plate guard, order status active, revision date 7/13/2020. 1. Record review of the face sheet for Resident #100 revealed the resident was admitted to the facility on [DATE] and was an [AGE] year-old male. Resident #100 had diagnoses which included, unspecified severe protein-calorie Malnutrition (reduced protein and calories). Record review of the physician order summary report for Resident #100, dated 4/27/22, revealed the resident had a diet order of, regular diet pureed texture, regular consistency, for pockets food, needs cueing to swallow regular consistency, order status active, order date 4/26/22 Record reviews of the admission MDS for Resident #100, dated 4/14/22, revealed the resident had a swallowing disorder listed as . Coughing or choking during meals or when swallowing medications and Complaints of difficulty or pain with swallowing . Record review of the current undated care plan for Resident #100 revealed the resident had a Focus stating, Resident is on a regular diet . Listed under Interventions/ task the care plan stated, Offered diet as ordered . 2. Record review of the face sheet for Resident #31 revealed a [AGE] year-old female admitted to the facility initially on 7/01/07 and readmitted on [DATE]. Resident #31 had diagnoses which included Dysphagia, Unspecified (swallowing disorder), Other Symptoms and Signs Involving Cognitive Functions and Awareness, Mild Protein-Calorie Malnutrition, Other Symptoms and Signs Involving Cognitive Functions Following Other Cerebrovascular Disease, And Other Speech and Language Deficits Following Unspecified Cerebrovascular Disease. Record review of the physician Order Summary Report dated 4/27/22, and facility Order Listing Report dated 04/25/ 2022, revealed Resident #31 had a diet of No salt on tray. Pureed texture, regular consistency, Order Status Active, Revision Date 2/26/2021 . Record review of the quarterly MDS for Resident #31, dated 3/09/22, revealed the resident had a Swallowing Disorder listed as Loss of liquid/solids from mouth when eating or drinking, Holding food and mouth/cheeks or residual food in mouth after meals, Coughing or choking during meals or when swallowing medications and Complaints of difficulty or pain with swallowing . Record review of the current undated care plan for Resident #31 revealed a Focus stating, Resident is on a therapeutic diet. NSOT (No salt on tray) Puree. Interventions/task listed stated . Offered diet as ordered . 3. Record review of the face sheet for Resident #4 revealed an [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had diagnoses which included Rhabdomyolysis and Dysphagia, Unspecified (swallowing disorder). Record review of the physician Order Summary Report dated 4/27/22 and facility Order Listing Report Dated: 04/25/2022 revealed Resident #4 was on a regular diet. Pureed texture, regular consistency, order status active, revision date 5/24/2021. Record reviews of the quarterly MDS for Resident #4, dated 1/18/22, revealed the resident had a Swallowing Disorder listed as . Coughing or choking during meals or when swallowing medications and Complaints of difficulty or pain with swallowing . Record review of the current care plan for Resident #4 revealed a Focus stating, Resident is on a regular diet: puree . Interventions/task stated . Offer diet as ordered . Record review of the Menu Matrix, Monday, (Facility) S S 2022 5 week NAV - week - 5 dinner menu revealed the following foods to be served for a regular pureed diet: pureed salmon croquette, puree cheesy ranch potatoes, puree green beans, pureed dinner roll and puree canned fruit. Record review of the Menu Matrix, Tuesday (Facility) S S 2022 5 week NAV - week - 5 noon menu revealed the following pureed foods to be served at the noon meal: Puree pot roast, puree roasted new potatoes, puree parsley carrots, puree garlic cheese biscuit and puree canned fruit. Observation and interview on 4/25/22 at 4:25 PM, revealed puree preparation in the kitchen. The Dietary Manager stated, at this time, she prepared for 6 purees. She was observed pureeing the cheese potato dish. After pureeing the potatoes, which she had added an unknown amount of milk, she took the temperature, and it was 154.8 degrees Fahrenheit. All other foods had been pureed previously. Observation of these foods on the steam table revealed the following: Pureed fish had dark whole bits visible in the food in the pan. Puree diced potatoes/cheese potatoes had skin and bits visible in the pan Pureed green beans had no obvious issues visible. On 4/25/22 at 5:20 PM a test tray was requested of the pureed foods from the Dietary Manager. The result of the testing, at this time was: Pureed bread had some solid bits of bread in it Pureed fish had some whole bits of fish Puree green beans had some bits of whole vegetables and there was a green bean string. Pureed potatoes had skins and bits of potato. Observation and interview on 4/26/22 beginning at 11:07 AM and concluding at 11:49 AM of the kitchen revealed Dietary Staff A stated she prepared six purees. She pureed the stew meat/pot roast with an unknown amount of gravy and placed it on the steam table at 164.5 degrees Fahrenheit (taken by Dietary staff A). She then pureed sliced carrots and added an unknown amount of carrot juice to the processor pureed it in a gray processor pot which had a crack in the side. The temperature was 175.6 degrees (taken by Dietary staff A) and placed on a steam table. She then placed wedged cooked potatoes in the processor pot, added milk and puree the mixture. The temperature was 150.3 degrees Fahrenheit (taken by Dietary staff A) in the pan on the steam table. At that time skins and bits of potato could be seen in the puree. It was also noticed that she assembled the parts of the processor for the next puree and it was noted the white blade was damaged and had missing original pieces on the exterior but it looked as though it had been repaired with a hard adhesive of some kind. She then placed biscuits that had grated cheese on top in the processor, added milk and pureed the mixture. She took the temperature, and it was 166 degrees Fahrenheit after being reheated. Meal service started at 11:49 AM. On 4/26/22 at 11:53 AM a test sample was requested of the pureed foods from the Dietary Manager. On 4/26/22 at 11:54 AM the result of the test tray was: Pureed cheese biscuit were slightly gummy Pureed sliced carrots had some chunks of whole carrot and bits Pureed wedge potato had skins visible and tasted and hard bits of food. The texture was very thick. Puree stew meat/pot roast was not in a puree form. The meat had to be chewed to be consumed. The meat, if swallowed, balled up in an individual's mouth and was not smooth. An observation and interview on 4/26/22 at 12:15 PM the Dietary Manager stated revealed they just got the gray topped processor blade Observation of the white blade, at this time, revealed it looked like it had been repaired with a hard brown substance and had the original white portions missing The Dietary Manager stated they gave it (white blade) to maintenance and they put something on it. During an interview on 4/26/22 at 12:17 PM Dietary staff A stated, This new one (processor) don't blend as well. During an interview on 4/26/22 at 12:18 PM, the Dietary Manager stated, the staff had not had training. Most (staff) had been at the facility a long time. It's time to retrain regarding purees. She stated the correct puree consistency should be Pudding-like consistency. Observation and interview on 4/26/22 at 12:25 PM revealed Resident #4 in his room feeding himself. He had oxygen via nasal cannula and was seated in his wheelchair. He was served pureed carrots, Ready Care supplement chocolate milk, and pureed cheese biscuit which there were bits of whole biscuit visible in it. The pureed cooked wedge potatoes had visible skins and whole bits. The pureed stew meat/pot roast with brown gravy was also served. At that time the resident tried to eat the stew meat/beef and then removed a balled-up portion of the meat out of his mouth and placed it on his meal tray. The state surveyor asked him why he had removed the meat from his mouth. He stated, I couldn't eat it. Observation on 4/26/22 at 12:29 PM of the meal tray of confused Resident #100 revealed he was served pureed cheese roll, stew meat, carrots, and potatoes in which bits and skins were visible in the potatoes. Observation on 4/26/22 at 12:30 PM revealed the meal tray for confused Resident #31 was served and had pureed cheese roll, pureed stew meat (none was consumed), pureed carrots, pureed fruit and pureed potatoes. There were visible bits and skins in the pureed potatoes. Interview on 4/26/22 at 12:31 PM with CNA B, she stated she fed Resident #31 lunch. She stated, the meat on his plate wasn't consumed because it wasn't pureed real good. She couldn't eat it. She tried a few bites. Interview on 4/26/22 at 12:56 PM with LVN A revealed Resident #4 was on a pureed diet because he had difficulty swallowing. Interview on 4/26/22 at 12:58 PM with LVN B revealed Residents #31 and #100 were on pureed diets because they had difficulty swallowing. Interview on 4/27/22 at 10:00 AM with the Maintenance Supervisor revealed He didn't remember fixing a kitchen blade. Interview on 4/27/22 at 10:49 AM with the Dietary Manager revealed they did not puree the foods long enough. At that time Dietary staff A also stated, Yesterday there was not enough pureeing time. The Dietary Manager further stated, (Dietary staff A) thought the new processor caused the puree problems. You have to leave this one on long. Dietary Manager stated, residents could choke and aspirate if the puree was not in the correct form. Dietary Manager stated, herself the cook and the helper were responsible for ensuring purees were in the proper form. The Dietary Manager stated she would retrain Staff on purees and she would train a new person. Interview on 4/27/22 at 1:37 PM with the Dietary Manager, she stated no dietary in-services were conducted in the last three months. She added, I'm doing a short one now. When asked about the cracked/damaged blade she stated, I pulled it. We can throw it away. Record review of the facility's policy titled Diet Manual 2014, revealed the following, Diet, The pureed diet is a texture modification of regular or therapeutic diets, designed to provide adequate nutrition for those persons with choking tendencies or difficulty with swallowing due to facial paralysis or other illness. This diet should be served only if no other consistency can be tolerated . The puree recipes are followed for regular diet items so that the consistency of pureed foods is that of a semisolid rather than a semi liquid. Pureed food should be the consistency of applesauce or pudding to Mashed potato consistency .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and or record review the facility failed to ensure resident rooms were designed or equipped to assure full visual privacy for 12 of 13 resident rooms reviewed, in that: The facility failed to ensure Twelve of 13 resident rooms, occupied by 2 residents, had privacy curtains that were not missing and would provide full visual privacy (201, 202, 203, 205, 206, 207, 408, 503, 505, 512, 601, and 609). This failure could place residents at risk of being exposed while receiving personal care. The findings include: Observation on 4/25/22 at 3:06 PM revealed room [ROOM NUMBER] had Resident #4 and Resident #43. There was no privacy curtain at the foot of the B bed. A resident in the B bed could be viewed while receiving personal care if another resident went to the restroom which was located on the B bed side. Resident #4 resided on the B bed side and had a catheter. Observation on 4/25/22 at 3:42 PM revealed room [ROOM NUMBER] had Residents #31 and #32. There was no privacy curtain at the foot of the B bed and the restroom was on the B bed side. Observation on 4/25/22 at 3:53 PM revealed room [ROOM NUMBER] had Residents #47 and #3. There was no privacy curtain at the B bed foot. The restroom was located on the B bed side. Observation on 4/25/22 at 4:00 PM revealed room [ROOM NUMBER] had Residents #20 and #39. There was no privacy curtain at the foot of the B bed and the restroom was on the B side of the room. The following observations were made during a tour of rooms on halls 200 and 600 that had two residents residing in each room: Observation on 4/25/22 at 6:12 PM revealed room [ROOM NUMBER] had no privacy curtain at the foot of the A or B bed and the restroom was on the B side of the room. Residents #8 and #11 resided in this room. Observation on 4/25/22 at 6:13 PM revealed room [ROOM NUMBER] had no privacy curtain at the foot of the B bed and the restroom was on the B side of the room Observation on 4/25/22 at 6:14 PM revealed room [ROOM NUMBER] had no privacy curtain at the foot of the B bed and the restroom was on the A side of the room but residents on the B side could still be viewed. Observation on 4/25/22 at 6:15 PM revealed room [ROOM NUMBER] had no privacy curtain on the foot of the B bed and the restroom was on the B side of the room. Observation on 4/25/22 at 6:15 PM revealed room [ROOM NUMBER] had no privacy curtain at the foot of the B bed and the restroom was on the A side of the room but residents on the B side could still be viewed. Observation on 4/25/22 at 6:15 PM revealed room [ROOM NUMBER] had no privacy curtain at the foot of the B bed and the restroom was on the A side of the room. Residents on the B side could still be viewed. Observation on 4/25/22 at 6:17 PM revealed room [ROOM NUMBER] had no privacy curtain at the foot of the B bed and the restroom was located on the B side of the room. Observation on 4/25/22 at 6:18 PM revealed room [ROOM NUMBER] had no privacy curtain at the foot of the B bed and the restroom was on the B side of the room. Observation on 4/27/22 at 11:14 AM revealed a posted certificate in the facility rotunda. It documented, Certificate of The Office of the State Fire Marshall. Fire Alarm Installation Certificate. [facility name] . State License . Completion Date 4/01/93, indicating initial certification was after this date. An interview on 4/26/22 at 8:40 AM with LVN B revealed in room [ROOM NUMBER] Resident #20 was occasionally incontinent. Her roommate Resident #39 was continent. room [ROOM NUMBER], Resident #31 was incontinent of bowel and bladder and her roommate Resident #32 was incontinent of bladder occasionally at night and he could transfer. room [ROOM NUMBER] had Resident #47 who was incontinent of bowel and bladder and could not walk or self-transferred. His roommate Resident #3 was incontinent of bowel and bladder and he transferred with assistant. An interview on 4/26/22 at 8:54 AM with LVN A revealed Resident #4 had a catheter and was incontinent of bowel. He could walk with a walker and transfer with assistance. Resident #43 was incontinent of bowel and bladder and couldn't transfer but could wheel himself in his wheelchair. An interview on 4/27/22 at 10:00 AM with the Maintenance Supervisor revealed the facility had no privacy screens or other additional types of privacy equipment. He also stated, housekeeping was over privacy curtains. An interview on 4/27/22 at 10:13 AM with BOM/Housekeeping Laundry Supervisor, she stated she had been over the laundry and housekeeping for approximately 2 years. She stated, Maintenance was responsible for taking them down and putting them up. An interview on 4/27/22 at 11:00 AM with the Maintenance Supervisor, he stated he did not know why the privacy curtains were missing at the B beds. he was told to put one in the middle and one by the door. He stated, the result for the resident not having a privacy curtain was the resident could be embarrassed. He further stated, he didn't know how long the privacy curtain had been down. Staff took them down during COVID. An interview on 4/27/22 at 11:09 AM with the Administrator regarding privacy. He stated, I took the curtains down in COVID. They harbor COVID. The Administrator stated that the privacy curtains should be put up once a second person was in the room. An interview on 4/27/22 at 11:24 AM , the Administrator stated the facility had no specific policy on privacy curtains. Record review of the facility document titled M DCP admission packet, revealed the following documentation, Resident [NAME] of Rights. Our facility will protect and promote each of the following rights . privacy and confidentiality. 18. You have the right to personal privacy and confidentiality of your personal and clinical records. Personal privacy includes privacy in accommodations, medical treatment, written and telephone communications, personal care .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public in 3 of 3 resident baths (hall 100/200, hall 400 and hall 500/600) and 1 of 1 soiled linen room (hall 400) reviewed, in that: 1. The facility failed to ensure chemicals were stored in a manner to prevent contamination of resident use items in resident baths (3 of 3 baths (100/200, 400 and 500/600). 2. The facility failed to ensure chemicals were stored in a secure area (hall 400 soiled linen room). 3. The facility failed to ensure shower chair mesh and vinyl was not soiled and in disrepair (3 of 3 baths (100/200, 400 and 500/600)). These failures could place residents at risk of chemical related injuries. The findings include: Observation on 4/25/22 at 3:20 PM revealed One of two shower chairs, on 400 hall, had the mesh back that was frayed and pulled away from the frame and there was a buildup of residue and dirt on the mesh back that included the bariatric chair. The sharps container was not secured to the wall. The locked cabinet in the room had a spray bottle of KQuat Select Cleaner and Disinfectant stored next to the washcloths, deodorant, skin and hair cleaner, body wash, toothpaste and shaving cream. The label on the bottle stated Danger . Corrosive. Causes irreversible eye damage. Harmful if swallowed or absorbed through the skin . Observation on 4/25/22 at 3:27 PM revealed the soil linen room on hall 400 had a door which was lockable but was unlocked. There were spray bottles of cleaners on the upper shelves which included KQuat Select. There was an unlocked sink cabinet which contained Clorox Clean Up Cleaner and Bleach which was labeled, Warning. Causes substantial but temporary eye injury. There were two spray bottles in the unlocked cabinet. The top shelf contained [NAME] Tub and Tile Cleaner which was labeled . May cause eye and skin irritation . This same observation was made on 4/25/22 at 6:05 PM and on 4/26/22 at 8:22 AM and at 3:58 PM. Observation on 4/25/22 at 3:34 PM of hall 500/600 bath revealed one of three shower chairs had a heavy buildup on the mesh back of dirt and residue, this was the pink shower chair. The cabinet in the room had shower body wash, lotion, shaving cream on the same shelf with a spray bottle of KQuat Select cleaner. One of two shower stalls had no privacy curtain, it had been removed from the track. There was no privacy curtain at the toilet and the curtain had been removed from the track. Observation on 4/25/22 at 5:52 PM of the hall 100/200 bath revealed a cabinet in the bath that contained KQuat Select and it was stored amongst shaving cream and resident toiletries. Two of the four shower chairs in the room had mesh backs which were dirty with residue and dirt. Two of the four shower chairs also had frayed mesh. The lounge shower chair had cracked vinyl on the headrest, the back pad and leg rest. When you press the headrest the water that was soiled would flow out of it. There was also dirt behind the leg rest vinyl and on the leg rest. Observation on 4/25/22 at 5:58 PM of the hall 500/600 bath revealed the cabinet had KQuat Select cleaner stored with body wash, shower shaving cream and resident toiletries. Observation on 4/26/22 at 8:26 AM of the hall 400 shower revealed there was a sign posted on the paper towel dispenser titled CNA Monday List, with the following documentation, . Shower cabinet . Keep it locked at all times. Cleaner needs to be inside shower cabinet, not on rail where resident can get to it . In the cabinet there was KQuat Select cleaner stored next to razors, toothpaste, toilet tissue and open container body wash. In an interview with CNA A on 4/26/22 at 8:30 AM, he stated, he had not noticed the sharps container was not secured to the wall. He said they were instructed to put the cleaners in the cabinet as was documented on the post a sign. Observation on 4/26/22 at 3:55 PM of hall 400 bath revealed the door was not lockable. The cabinet had KQuat Select cleaner stored next to toilet tissue and body wash. There was a sign posted in the bath that stated that cleaner should be stored in the cabinet. The sharps container was not secured to the wall and the light in the shower stall was not operational. Observation on 4/26/22 at 4:00 PM of hall 500/600 bath revealed the entrance door was not lockable, the cabinet was unlocked and contained KQuat Select cleaner stored on the shelf with body wash and resident toiletries and a scrub puff. One of three (pink) shower chairs had a buildup on the mesh back of dirt and residue. The ceiling heating unit fan was not operational, and the heating element did not work. Observation on 4/26/22 at 4:59 PM of the hall 100/200 bath revealed the door was not lockable. The cabinet contained K Quat cleaner in a thin plastic bag and was still on the shelf with body wash and resident toiletries. Two or four shower chairs had frayed mesh back with buildup, residue and dirt, this was the blue bariatric and the small blue shower chairs. The pink lounger shower chair had the same cracked vinyl on the headrest back rest and the leg rest. The surface underneath the leg rest was dirty and had to build up of dirt when you press the headrest water streamed out of the headrest that was soiled. In an interview on 4/27/22 at 9:50 AM with the hall 200 Nurse Aide A revealed staff wiped and sanitized them between residents. She stated she didn't know, regarding deep cleaning. She stated, she didn't know anything about the cracked vinyl or the soiled water that leaked out of the headrest. She stated the result of residents using equipment that was not clean could be infection if the resident has a wound. She stated, the facility kept the chemical in the cabinet to keep residents from getting ahold of it. She stated, if the facility continued to store chemicals with their toiletries the chemicals could get into the toiletries and contaminate and cause irritation to the resident. She stated they were instructed to store chemicals in the cabinet. She stated, another worker told her to store chemicals in a cabinet. At that time it was noted KQuat Select cleaner was stored in a thin plastic bag in a bin with resident hair conditioner cuticle sticks and razors. There was also the CNA Monday List sign posted in the cabinet that stated to store the cleaner in the cabinet. Observation on 4/27/22 at 10:18 AM of the 500/600 bath revealed one of three shower chairs was heavily soiled on the mesh back. In the cabinet KQuat Select was stored with resident toiletries there was no sign on the cabinets saying to store the chemical there. There was also body wash located in the cabinet. Interview on 4/27/22 at 10:25 AM with hall 500 CNA B revealed they washed the shower chairs, between residents, with this disinfectant spray. She then showed the state surveyor a spray bottle of KQuat Select that was in the cabinet. She stated, they had not mentioned storage of chemicals in any trainings. She stated they usually had it hanging on the glove box bracket on the wall. She added, after use they stored in the cabinet. She stated the result for the resident if chemicals were stored amongst their toiletries was it could explode. She added, deep cleaning was done on Saturdays and Sundays. Everything was cleaned. She stated, residents could get a rash and the soil/dirt could get on their skin if residents used soiled shower chairs. Interview on 4/27/22 at 10:35 AM with the DON , she stated regarding chemical storage in the baths, it should remain locked up. They were trained to store chemicals in the locked cabinet She stated the chemicals shouldn't be stored together. She stated, I'm not going to speculate the result of residents being showered on a soiled shower chair. She added, all chairs were cleaned three times a week on the night shift. They were wiped down with disinfectant. The Administrator stated at this time that ultimately the CNA was responsible for ensuring the shower chairs were cleaned and in good repair. Housekeeping did deep cleaning in the showers. CNA's were to report repairs to the administrator and maintenance. During and observation and interview on 4/27/22 at 1:32 PM of the hall 400 soil linen room revealed the door was unlocked and the same chemicals (KQuat Select and [NAME] Tub and Tile) were on the top shelf and in the unlocked sink cabinet. The Administrator stated at this time, The chemicals should be stored next door (housekeeping closet). Record review of the facility's policy titled Environment of Care Policy and Procedure Manual 2003, HM03 - 6.0, revealed the following documentation, Storage and Handling of Hazardous Chemicals . 3. Chemicals will be stored in properly labeled containers with special attention given to hazardous warnings. Their warnings will alert employees using the chemicals not to store incompatible materials in the same area. Chemicals need to be stored by their potential hazard, not alphabetically . 5 . Compressed gas cylinders should be secured and supported. 6. Each employee should read the manufacturer or suppliers directions before using any product noting the possible hazards, both physical and health, of the product .